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    Perubahan Paradigma Akreditasi Baru TOT Jun 2012

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    putrapaninjauan
    This document provides information about changes to the hospital accreditation paradigm and standards in Indonesia in 2012. It includes: - An overview of new international principles and standards that are the basis for accreditation, focusing on patient-centered care and continuous quality improvement. - Details of the new standards in Indonesia, which are organized into four groups: clinical standards, management standards, patient safety goals, and Millennium Development Goals. - How accreditation is intended to maximize quality and safety, and drive continuous improvement through periodic assessment and planning for enhancements.

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    Perubahan Paradigma Akreditasi Baru TOT Jun 2012

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    putrapaninjauan
    40 views40 pages
    This document provides information about changes to the hospital accreditation paradigm and standards in Indonesia in 2012. It includes: - An overview of new international principles and standards that are the basis for accreditation, focusing on patient-centered care and continuous quality improvement. - Details of the new standards in Indonesia, which are organized into four groups: clinical standards, management standards, patient safety goals, and Millennium Development Goals. - How accreditation is intended to maximize quality and safety, and drive continuous improvement through periodic assessment and planning for enhancements.

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    This document provides information about changes to the hospital accreditation paradigm and standards in Indonesia in 2012. It includes: - An overview of new international principles and standards that are the basis for accreditation, focusing on patient-centered care and continuous quality improvement. - Details of the new standards in Indonesia, which are organized into four groups: clinical standards, management standards, patient safety goals, and Millennium Development Goals. - How accreditation is intended to maximize quality and safety, and drive continuous improvement through periodic assessment and planning for enhancements.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    40 views40 pages

    Perubahan Paradigma Akreditasi Baru TOT Jun 2012

    Uploaded by

    putrapaninjauan
    This document provides information about changes to the hospital accreditation paradigm and standards in Indonesia in 2012. It includes: - An overview of new international principles and standards that are the basis for accreditation, focusing on patient-centered care and continuous quality improvement. - Details of the new standards in Indonesia, which are organized into four groups: clinical standards, management standards, patient safety goals, and Millennium Development Goals. - How accreditation is intended to maximize quality and safety, and drive continuous improvement through periodic assessment and planning for enhancements.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 40

    PERUBAHAN

    PARADIGMA DALAM
    AKREDITASI
    VERSI 2012
    UNTUK SURVEIOR*

    DR.Dr.Sutoto,M.Kes

    Curiculum Vitae: Dr.dr.Sutoto,MKes


    Tempat/Tgl lahir :Purwokerto, 21 Juli 1952
    JABATAN SEKARANG:
    1. Ketua umum PERSI Th 2009-2012
    2. Ketua KARS Th 2011-2014
    PENGALAMAN ORGANISASI
    1. Ketua :IRSPI (Ikatan RS Pendidikan Ind) Th 20052008
    2. Ketua :ARSPI (Asosiasi RS Pendidikan Ind) Th 20082010
    3. Ketua IRSJAM (Ikatan RS Jakarta Metropolitan)
    2008-2010
    PENDIDIKAN:
    1. SI Fakultas Kedokteran Univ Diponegoro
    2. SII Magister Manajemen RS Univ. Gajahmada
    3. S III Manajemen Pendidikan Universitas Negeri Jakarta (Cumlaude)
    PENGALAMAN KERJA
    1. Staf Pengajar Pascasarjana MMR UGM, UHAMKA, UMY, UNSOED
    2. Surveyor Komisi Akreditasi Rumah Sakit (KARS):
    3. Kepala Puskesmas Purwojati, Banyumas, Jawa Tengah,1978-1979
    4. Kepala Puskesmas Jatilawang, Banyumas,jawa Tengah., 1979-1992
    5. Direktur RSUD Banyumas Jawa Tengah 1992-2001
    6. Direktur Utama RSUP Fatmawati Jakarta 2001 S/D 2005
    7. Direktur Utama RS Kanker Dharmais Jakarta 2005-2010
    2
    8. Sesditjen Binyanmed KEMENKES R.I( Feb-sept 2010)

    Komisi Akreditasi Rumah Sakit

    Frost and Sullivan contend that Malaysia has been gaining over

    Singapore in attracting Indonesian patients. It said: Indonesian


    medical tourists going to Malaysia comprise around 70 percent
    of its total (inventory of international patients, while those going
    to Singapore are only around 65 percent.
    Last year, Malaysian hospitals treated 288,000 Indonesian
    patients, up from 221,538 in 2007 and 170,414 in 2006.
    In 2007, Singapore hospitals treated 226,200 Indonesian
    patients, a drop from the 266,500 recorded in 2006. However, its
    revenue in 2007 from this market was recorded to have
    increased.

    Source: International Medical Travel Journal

    Sebagian masyarakat Indonesia berobat


    keluar negeri

    HARIAN
    ANALISA
    ONLINE

    15 MEI 2012

    Accreditation Better Quality of Care


    Accreditation is considered a standard through
    which a healthcare facility or service is shown to offer
    quality and healthcare that meet minimum standards and
    guidelines offered by various domestic and international
    quality boards.

    Accreditation: A World Trend


    The U.S., Canada, and Australia have the oldest

    accreditation systems
    In Europe, Germany, France, Ireland, and Spain have new
    accreditation systems
    In Asia, China, Thailand, and Malaysia are developing
    national accreditation programs
    The WHO, World Bank, and development banks
    recognize and endorse the accreditation model
    The International Society for Quality in Health Care
    (ISQua) accredits accrediting bodies

    The International Society


    for Quality in Health Care
    (ISQua)
    The International Society for Quality in Health

    Care (ISQua) launched its International


    Accreditation Programme (IAP) in 1999.
    This is the only international programme that
    'Accredits the Accreditors'.
    As of January 2011 there are 17 organisations, 31
    sets of standards from 23 organisations, and 6
    surveyor training programmes currently
    accredited by ISQua.

    International Hospital
    Accreditation

    Joint Commission International (JCI): Thailand,


    Singapore, India, malaisya, South America, Egypt,
    Jordan, Hungary, Turkey and Croatia
    Trent Accreditation Scheme aka Trent (U.K.,
    Europe, Hong Kong, Malta, Philippines)
    The United Kingdom Accreditation Forum
    (UKAF)
    Australian Council for Healthcare Standards
    International (ACHSI)
    Canadian Council on Health Services Regulation
    (CCHSA)

    SUMBER ACUAN AKREDITASI RS


    BARU
    1. International Principles for Healthcare Standards,

    A Framework of requirement for standards, 3rd


    Edition December 2007, International Society for
    Quality in Health Care / ISQua
    2. Joint Commission International Accreditation
    Standards for Hospitals 4 rd Edition, 2011
    3. Instrumen Akreditasi Rumah Sakit, edisi 2007,
    Komisi Akreditasi Rumah Sakit / KARS
    4. Standar-standar spesifik lainnya.

    12

    WHAT IS ACCREDITATION
    INTENDED TO ACCOMPLISH
    Maximize quality/minimize safety

    risk
    Improve patient care processes
    and outcomes
    Enhance patient safety
    Strengthen the confidence of
    patients, professionals, and payors
    about the organization
    Improve the management of health
    services
    Enhance staff recruitment,
    retention, and satisfaction
    Provide education on better/best
    practices

    INTERNATIONAL ACCREDITATION
    PHILOSOPHY
    1. Maximum

    achievable
    standards
    2. Patient-centered
    3. Process stimulates
    continuous
    improvement

    The Accreditors Tools


    1.
    2.
    3.
    4.
    5.

    Standards
    Evaluation
    Methodology
    Patient Safety Goals
    and Tools
    Data on Performance
    and benchmarks
    Education

    KONSEP DASAR MUTU STANDAR INTERNASIONAL


    AKREDITASI
    (Joint Commission International, 4th Editon ,
    2011)

    Building an Efficient & Effective


    Clinical/Patient Safety System
    Building an Efficient & Effective
    Management & Operational System

    Building an Efficient & Effective


    Clinical/Patient Safety System
    1. International Patient Safety Goals
    2. Access to care & Continuity of Care
    3. Patient & Family Rights

    4. Assessment of Patients
    5. Care of patients
    6. Anesthesia & Surgical Care

    7. Medication Management & Use


    8. Patient & Family Education

    Building an Efficient & Effective


    Management & Operational System
    1. Quality Improvement & Patient Safety
    2. Prevention & Control of Infection
    3. Governance, Leadership & Directions

    4. Facility Management & Safety


    5. Staff Qualifications & Education
    6. Management of Communication &

    Information

    Standar Akreditasi Rumah Sakit


    Baru
    Standar

    Kelompok I
    Kelompok II
    Kelompok III
    Kelompok IV
    Total :

    161
    153
    6
    3
    323

    Elemen
    Penilaian
    436
    569
    24
    19
    1048
    19

    Standar Akreditasi Rumah Sakit Baru


    Versi 2012
    I. Kelompok Standar Pelayanan Berfokus pada Pasien
    II. Kelompok Standar Manajemen Rumah Sakit
    III. Sasaran Keselamatan Pasien Rumah Sakit
    IV. Sasaran Milenium Development Goals

    20

    Standar Akreditasi Rumah Sakit Baru


    Versi 2012
    I. Kelompok Standar Pelayanan Berfokus pada Pasien
    Bab 1. Akses ke Pelayanan dan Kontinuitas
    Pelayanan (APK)
    Bab 2. Hak Pasien dan Keluarga (HPK)
    Bab 3. Asesmen Pasien (AP)
    Bab 4. Pelayanan Pasien (PP)
    Bab 5. Pelayanan Anestesi dan Bedah (PAB)
    Bab 6. Manajemen dan Penggunaan Obat (MPO)
    Bab 7. Pendidikan Pasien dan Keluarga (PPK)

    21

    Standar Akreditasi Rumah Sakit Baru


    Versi 2012

    II. Kelompok Standar Manajemen Rumah Sakit


    Bab 1. Peningkatan Mutu dan Keselamatan Pasien
    (PMKP)
    Bab 2. Pencegahan dan Pengendalian Infeksi (PPI)
    Bab 3. Tata Kelola, Kepemimpinan, dan Pengarahan (TKP)
    Bab 4. Manajemen Fasilitas dan Keselamatan (MFK)
    Bab 5. Kualifikasi dan Pendidikan Staf (KPS)
    Bab 6. Manajemen Komunikasi dan Informasi (MKI)
    22

    Standar Akreditasi Rumah Sakit Baru


    Versi 2012
    III. Sasaran Keselamatan Pasien Rumah Sakit
    Sasaran I : Ketepatan identifikasi pasien
    Sasaran II : Peningkatan komunikasi yang efektif
    Sasaran III : Peningkatan keamanan obat yang perlu
    diwaspadai (high-alert)
    Sasaran lV : Kepastian tepat-lokasi, tepat-prosedur, tepatpasien operasi
    Sasaran V : Pengurangan risiko infeksi terkait pelayanan
    kesehatan
    Sasaran VI : Pengurangan risiko pasien jatuh

    23

    Standar Akreditasi Rumah Sakit Baru


    Versi 2012

    IV. Sasaran Milenium Development Goals


    Sasaran I : Penurunan Angka Kematian Bayi
    dan Peningkatan Kesehatan Ibu
    Sasaran II : Penurunan Angka Kesakitan
    HIV/AIDS
    Sasaran III : Penurunan Angka Kesakitan TB
    24

    PERUBAHAN PARADIGMA
    SURVEIOR
    Walking
    arround
    Tracer

    Methodology
    Santun
    Team work
    Fokus pada
    standar
    peningkatan

    Perubahan Paradigma Rumah Sakit


    Standar Akreditasi Baru
    1. Peran direktur sangat sentral
    2. Tujuan utama Peningkatan mutu
    3. Standar Akreditasi harus dinamis

    4. Pelayanan berfokus pada pasien


    5. Keselamatan Pasien menjadi standar utama
    6. Kesinambungan pelayanan
    7. Perbaikan terus menerus

    Akreditasi Sebagai Upaya


    Peningkatan Mutu Berkesinambungan
    AKREDITASI

    AKREDITASI

    TAHUN

    Akreditasi Sebagai Upaya CQI


    (CONTINUOUS QUALITY IMPROVEMENT)
    SURVEILANCE

    AKREDITASI

    SURVEILANCE

    SURVEILANCE

    AKREDITASI
    SURVEILANCE

    PPS

    AKREDITASI
    TAHUN

    Hasil penilaian
    Rekomendasi surveior ttg standar apa saja

    yang belum dipenuhi


    Rumah sakit setelah menerima sertifikat
    wajib membuat Perencanaan perbaikan
    strategis (PPS)
    PPS akan ditinjau setiap tahun oleh surveior
    pendamping

    PERENCANAAN PERBAIKAN STRATEGIS


    (PPS)
    ADALAH RENCANA TINDAKAN YANG WAJIB DIBUAT TERTULIS
    SETELAH RS MENDAPAT SERTIFIKAT AKREDITASI SEBAGAI
    BUKTI UPAYA PENINGKATAN MUTU BERKESINAMBUNGAN
    BERUPA RESPON TERHADAP HASIL REKOMENDASI
    SURVEIOR
    1. Merupakan strategi/pendekatan yang akan diambil untuk memenuhi setiap
    persyaratan yang belum terpenuhi
    2. Menjelaskan tindakan spesifik yang akan dilakukan RS untuk mencapai hasil
    sesuai Standar / elemen penilaian yang yang belum terpenuhi
    3. Menjelaskan metoda yang dipakai untuk perbaikan/ pemenuhan standar dan
    elemen penilaian guna perbaikan mutu berkesinambungan
    4. Mengidentifikasi indikator pencapaian (berupa data) untuk mengevaluasi
    efektivitas dari rencana perbaikan itu dan akan dicek setiap tahun oleh
    surveior pendamping

    Hasil Penilaian Survei


    Akreditasi Baru
    100
    90
    80
    70
    60
    50
    40
    30
    20
    10
    0
    DASAR
    PRATAMA

    MADYA

    UTAMA

    PARIPURNA

    CARA PENILAIANNYA:
    Pembagian Group BAB
    Group Mayor: Nilai >80%
    Group Minor: Nilai >20%

    PENILAIAN
    ELEMEN PENILAIAN = SKOR = O/5/10
    STANDAR = NILAI DALAM PERSEN
    BAB = NILAI DALAM PERSEN
    GROUP =NILAI DALAM PERSEN

    Pratama
    1.

    Sasaran keselamatan pasien rumah sakit

    2.

    Hak pasien dan keluarga (HPK)

    3.

    Pendidikan pasien dan keluarga (PPK)

    4.

    Peningkatan mutu dan keselamatan pasien


    (PMKP)

    5.
    6.
    7.
    8.
    9.
    10.
    11.
    12.
    13.
    14.
    15.

    Millenium Development Goals (MDGs)


    Akses Pelayanan dan Kontinuitas Pelayanan (APK)
    Asesmen Pasien (AP)
    Pelayanan Pasien (PP)
    Pelayanan Anestesi dan Bedah (PAB)
    Manajemen Penggunaan Obat (MPO)
    Manajemen Komunikasi dan Informasi (MKI)
    Kualifikasi dan Pendidikan Staff (KPS)
    Pencegahan dan Pengendalian Infeksi (PPI)
    Tata Kelola, Kepemimpinan dan Pengarahan ( TKP)
    Manajemen Fasilitas dan Keselamatan

    Mayor

    Minor

    Madya
    1.

    Sasaran keselamatan pasien rumah sakit

    2.

    Hak pasien dan keluarga (HPK)

    3.

    Pendidikan pasien dan keluarga (PPK)

    4.

    Peningkatan mutu dan keselamatan pasien (PMKP)

    5.

    Millenium Development Goals (MDGs)

    6.

    Akses Pelayanan dan Kontinuitas Pelayanan (APK)

    7.

    Asesmen Pasien (AP)

    8.

    Pelayanan Pasien (PP)

    9.
    10.
    11.
    12.
    13.
    14.
    15.

    Pelayanan Anestesi dan Bedah (PAB)


    Manajemen Penggunaan Obat (MPO)
    Manajemen Komunikasi dan Informasi (MKI)
    Kualifikasi dan Pendidikan Staff (KPS)
    Pencegahan dan Pengendalian Infeksi (PPI)
    Tata Kelola, Kepemimpinan dan Pengarahan ( TKP)
    Manajemen Fasilitas dan Keselamatan

    Mayor

    Minor

    UTAMA
    1.

    Sasaran keselamatan pasien rumah sakit (SKP)

    2.

    Hak pasien dan keluarga (HPK)

    3.

    Pendidikan pasien dan keluarga (PPK)

    4.

    Peningkatan mutu dan keselamatan pasien (PMKP)

    5.

    Millenium Development Goals (MDGs)

    6.

    Akses Pelayanan dan Kontinuitas Pelayanan (APK)

    7.

    Asesmen Pasien (AP)

    8.

    Pelayanan Pasien (PP)

    9.

    Pelayanan Anestesi dan Bedah (PAB)

    Mayor

    10. Manajemen Penggunaan Obat (MPO)

    11. Manajemen Komunikasi dan Informasi (MKI)


    12. Kualifikasi dan Pendidikan Staff (KPS)

    13. Pencegahan dan Pengendalian Infeksi (PPI)


    14. Tata Kelola, Kepemimpinan dan Pengarahan ( TKP)
    15. Manajemen Fasilitas dan Keselamatan (MFK)

    Minor

    Paripurna
    1.

    Sasaran keselamatan pasien rumah sakit (SKP)

    2.

    Hak pasien dan keluarga (HPK)

    3.

    Pendidikan pasien dan keluarga (PPK)

    4.

    Peningkatan mutu dan keselamatan pasien (PMKP)

    5.

    Millenium Development Goals (MDGs)

    6.

    Akses Pelayanan dan Kontinuitas Pelayanan (APK)

    7.

    Asesmen Pasien (AP)

    8.

    Pelayanan Pasien (PP)

    9.

    Pelayanan Anestesi dan Bedah (PAB)

    10. Manajemen Penggunaan Obat (MPO)


    11. Manajemen Komunikasi dan Informasi (MKI)
    12. Kualifikasi dan Pendidikan Staff (KPS)
    13. Pencegahan dan Pengendalian Infeksi (PPI)
    14. Tata Kelola, Kepemimpinan dan Pengarahan ( TKP)
    15. Manajemen Fasilitas dan Keselamatan (MFK)

    Mayor

    SEKIAN
    TERIMA KASIH

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